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iiimMARION COUNTY BUILDING INSPECTION INDIVIDUAL ON-SITE SEWAGE SYSTEM RECORD <br /> 5155 Silverton Rd NE <br /> SALEM OR 97305 (to be completed by system installer) <br /> 503-588-5147 PERMIT NO. `L'2- jI 7,c 7 <br /> MARION <br /> COUNTY http://www.co.marion.or.us/PW/Buildinglnspection t-k,:i ,S . 5c OK, <br /> SITE ADDRESS:4a � �-�� <br /> AS-BUILT PLAN OF CONSTRUCTED SYSTEM: <br /> Scale: 1"= <br /> 1-- <br /> No <br /> M.L.,tt...42) ) 7' ,...„F <br /> 6yai0A' ,_, ,-F,c,,,,A. 41 _ <br /> ,„.. ..T./ - . <br /> f <br /> 1' <br /> I <br /> / \ ....7,4 <br /> ,r - a <br /> ., z, " �.- <br /> d <br /> (show all details and dimensions necessary to 1 cate a l components of the system in the future) <br /> SYSTEM MATERIALS AND SPECIFICATIONS: INSTALLERS CERTIFICATION: <br /> I HEREBY CERTIFY THAT THE ON-SITE SEWAGE SYSTEM IN- <br /> System Design Sewage Flow> Gallons/Day STALLED AT THE ABOVE ADDRESS WAS CONSTRUCTED IN ACCOR- <br /> TANK Size: I COO total gallons [ ] single compartment DANCE WITH THE REQUIREMENTS OF THE PERMIT AND THE RULES <br /> Manufacturer: j,�,3c, {�{ <br /> [ ] double compartment OF THE ENVIRONMENTAL QUALITY COMMISSION. <br /> Material: flow-through [ ave tested the septic tank and certify it to be watertight. <br /> Effluent Sewer:„ Header Pipe: /I The system was installed by: <br /> Size/Mat'l L £40 �� Size/Mat'l ,(^,t0 t-( [ I Property Owner(permittee) <br /> [i,j,Ltcensed Sewage Disposal Service <br /> DRAINFIELD rock depth(inches) Box(es) <br /> Rock and under pipe Q.« I I Drop I I Concrete DEQ License Number: 123acj <br /> Pipe total depth 1_2.1. I I Distribution I I Plastic <br /> DEQ Certification Number: <br /> Drainfield Material(Altemative or perf.pipe) <br /> Total Drainfield Footage, 5tTrench Depth Minimum Maximum - <br /> Curtain Drain Depth Signed: L'.---r <br /> Effluent Pump: Pump Model . <br /> Pump cycle {r{�am, <br /> times in minutes: on - off Gallons per Cycle Company name: j (. `S"f i c. <br /> ATT Make and Model (please print) <br /> Attach an additional sheet for components and materials not listed above. Date: 1(Di5/7-7 <br /> (For Marion County Use Only) The above septic system has been inspected by Marion County. The information has been determined to be accurate <br /> and the system is: [)[.Approved I I Appr with corrections: see inspection report I I Denied <br /> Signed: it! . k t p!(T Date: <br /> MC:S-41 rev:3/03;4/12;5/14;11/17 G:\Forms\Septi \S-41 As-BuiIt20I 5Version2017.doc WHITE:Marion County; YEIJLOW:Otvner;PINK:Installer <br />